I have been doing a great deal of orientations lately due to unforeseen staffing issue. Anyway, it is always interesting when you orienting a new person to see what they really know and what they tell you they know. Somehow they never quite meet. But it gives me a chance to expand my horizons, teach new things, and learn that greatest of skills: patience. (This lesson usually coming after I have had another run-in with my 16-year-old.)

It was on one of those orientation nights when I realized doing a set up for a sleep study and doing it correctly are two different things. I also realized that my need for doing things according to AASM protocol confuses a great many new people. In particular, the need for all my technicians to measure the patients head. It amazes me how so few technicians know how to do this.

And then, even if they do, they do not understand how to put on a lead without pushing on the lead so hard that you think it is going to become a permanent part of the patient's body. To me, this is a basic skill that was learned within the first two weeks of becoming a technician.

Then, there is the middle of the night lead fix. Now, I was taught you want to disturb the patient as little as possible, so if you can wait for an arousal or awakening, great. Do you really want to go knocking on the door, reintroduce yourself, and explain what you are doing to a person at 2:30 in the morning?

I personally think the more unobtrusive you are, the quicker the patient will go back to sleep. I do not even turn the light on. I can usually correct the problem just from the light the hallway gives off. There is always the concern about the patient who will wake up swinging, but those patients usually tell you before lights out not to touch them when you wake them in the morning. Of course, I have had a patient or two over the years take a swing at me, but I have learned how to duck very quickly when necessary.

Lastly, it amazes me how little people document. Of course I am of the belief if you did not write it, it did not happen. (A lesson taught to me at one of the hospitals by their lawyer during orientation.) I think that lesson has stuck with me low this 20 plus years.

I think new techs are afraid to write too much. Me, personally: I am afraid of writing too little. I tell all new techs that they should pretend they are the reading doctor and they have received the study the next day but they have no video. Write to me so that I know why what I am seeing looks the way it does.

If that does not work, I use the lawsuit scenario. Its five years from now, you just received a request to show up at court about a sleep study you did eight years ago. How are you going to know what you did? What was going on? Write it out and it will never be a problem. That usually scares people to my way of thinking.

I know that orientation is important and needs a great deal of attention, but I really hope that they will get easier over time. I really believe that as our field gets more regulated and licensed, we will all be working on the same page to create the best sleep studies possible.

I am what you would call a sleep nerd. You know the type. I love those nights when the patient has something unusual or the perfect tracing. I just love to watch them, then talk about them with my fellow technicians.

Take the other night. I am working nights and have two patients. One is a very high stress patient who needs a great deal of attention. He kept insisting he had to have the television on or he would leave. The other patient was a very quiet man who was in the lab because he was tired all the time and asked for an early lights out. When I finally got the chance to sit down and look at his study, I found he had perfect Cheyne Stokes respirations. To me this is so cool. Not so much for the patient but as a technician we very rarely get the opportunity to see this and his was almost exactly the same: every episode nine breathes in an increasing then decreasing volume followed by twenty to twenty-five seconds central apnea and then it would start again. His EEG was not easy to read due to alpha intrusion but I am sure that was due to the medications and health issues this particular patient had.

So what do I do while working the next night with one of the new technicians? I show him the study. Of course, he finds it as fascinating as I do. Then he tells me the story about the patient he had that he picked up on central apnea and how he was able to get a good titration using BiPAP. This, of course, leads to the discussion of AutoSV and how we like that for treating central apnea. He also requests that he be there when my patient comes back for his titration study.

What this really comes down to is that I love working in the field of sleep, whether it is day shift or night shift, because I get to learn something new from each of my patients and more than every once in a while I get to make a difference in their life. Of course, this also means my kids and husband know more about sleep than they really want to and that at an average dinner party, I am probably one of the most boring conversationalists there. Oh well, at least they know that they really should get a good night's sleep and if they have a problem they should go talk to their doctor.

Every time I get a new patient I think "What mask I am going to use?" I think about what we have available now, what we used to have available, and who is going to perform the study.

Everyone has a favorite mask. Everyone who has been in the field for a long period of time has seen their favorite mask change over time.

When I was first doing home care for Bane Respiratory many years ago, I had specific masks for specific types of patients. I always started with the nasal mask except if the patient was claustrophobic or had fragile skin.

Then we would get into some of the stranger masks out there. I had a mask I used specifically for my little old ladies who went to the hair dresser once a week. (These little ladies were always my favorites)

Back then, I would use mostly the new gel masks that you had to boil to make fit. It served two purposes. One, to get the mask fit properly and two, I would see what medications they were taking and make sure they did not have three bottles of the same med by different names that they were taking. If I was calling a doctor's office in the middle of the day, they know I was calling because I had just found someone who was overmedicating themselves. It was always about patient care.

If I had one of my little old ladies who did not want to muss their hair, I would break out a mask that was a cross between a wrestler's headgear and Princess Leah's hairdo. But oh, the things you could do with it to get a patient to wear their CPAP or BiPAP. I almost never put the straps where they were supposed to go. This way I had one strap across the forehead and one at the back of the neck and the nasal cushion secured using Velcro around the hose. The great part was that this mask was one of the first where a patient could wear glasses so they could read in bed before lights out.

Full face masks to this day I use whenever someone is claustrophobic and the wires do not bother them. This means it is not having something touching their face that keeps them from wearing the mask but it is a control issue. When you tell someone to breathe through their nose only you take away some of their control. With a full face mask and having the patient hold it to their face they are in control and they learn to adjust to using CPAP. I have many successes that way.

In the end, choosing masks is all about how much communication I have with the patient. I will always give them at least two choices, I will always listen to their fears and any health issues and I will always look at my biocals for upper airway resistance. Then I give choices. This is how I find the pea under the shell almost every time.

The MWT, for those who are not in sleep, is the Maintenance of Wakefulness test. It is given to those who are on CPAP and need to stay awake for their job such as truck drivers, airline pilots, and train conductors. It is a series of 4 "naps" each lasting 40 minutes where you sit reclined in a low lit room with no noise and you are not to make any repetitive movements that might keep you awake.

Now if you have ever met me you know two things about me: One, I am a fidgeter, and, two, I am a foot tapper to end all foot tappers. I could probably get into the Guinness Book of World Records for tapping my foot so much. So the idea of taking those two behaviors away from me sounds like torture-even if it is only for 40 minutes. And if I could not tap or fidget I would probably end up tapping my fingers or falling asleep.

Now, just imagine you are doing a sleep study and it is totally quiet (that includes the fact that the patient you are watching is a quiet breather and does not snore) and you have the lights turned down to night light level. Now tell me: how you are supposed to stay awake for that?

I have technicians who turn the lights off during the night and I just can not imagine how they stay awake. I want light and noise. Otherwise it is nighty night time for me.

The last MWT I did, I was absolutely amazed at the guy. He came in as soon as he got up that morning. Skipped his morning coffee and followed all the directions. He was set up and ready to do his first nap. He got in the room, relaxed and I explained the test to him, turned off the light, and he did great. He stayed awake through the first three naps like a pro.

The fourth nap came after he had lunch. I should have known. I turn off the lights and started the test. Two minutes later, he is snoring away. I felt so bad. I wanted to help him but I had my job to do. I finished the test, scored it, and sent it to the doctor.

The worst part of my job is to call the patient to tell them the results of the test.

In the end, what I am really grateful for is that I do not have to take this test so that I can perform my job. I know that there are times I have to fight to stay awake, but at least I can get up and walk.

I just wonder how many truck drivers, pilots, and conductors really need this test and have not gotten it.

I am currently remote scoring for a lab in Ohio. It has been having a great deal of internet issues and so I called the office to see if someone was there that could help. The young lady who answered took the opportunity to ask me some questions about the exam and what to expect.

The first thing she asked, though, was how long ago I took the test. The problem being, that if I took it awhile ago then I probably would not know what to expect. The thing is that although some of the rules have changed, for the most part the test structure really has not changed.

Well, that brought me back to when I first learned sleep.

I was working as a respiratory therapist in an inner city hospital. I truly enjoyed my patients but I knew I was burned out. I was working the ED night shift one night, and in came a guy who had been gored by a bull. When you think about it: what more could I see? It really is the last thing you expect at 02:00am.

So, after talking to my manager, I decided I would try sleep.

I had four days of orientation. To say the guy who trained me did not want me there was an understatement. He liked his solitude. He said "put the leads here, put these filters on and monitor the patient." That was it. He gave me a diagram for lead placement I used for the first three months while I was working. I thought this is easy...

...Until I took a registry review class. I did not know how much I did not know until then.

While I was there someone took pity on me and gave me an R and K manual. Other people drew me pictures of the 10/20 system.

I spent the next month rewriting our policies for correct lead placement and filter settings and I taught myself to score using the R and K manual. I would literally hold it up to the screen and figure out what stage the patient was in. Fortunately the EKG and respiratory events were pretty easy for me to figure out.

Titration became a whole different matter.

I learned to sit on my hands. As a respiratory therapist I want to fix a desaturation with all my being. I am not one to sit and watch a person desat to 80% or lower and not intervene.

I learned. I became the go to guy or gal for my reading doctor. I learned how interesting sleep was.

I would never trade my first year for anything. I will, however, do what I can to make sure no one has to go through their first year the same way I did.

I love to mentor new technicians and I hope to always be there to answer their questions when they need it.

I always have lofty goals for myself. I am one of those people who is always trying to improve. So, this year, I do not feel that the status quo is a good thing. So, this year, I was thinking: what do I want to improve?

My friends on Binary Sleep have joined forces to lose weight on the million pound challenge. I know I could stand to lose oh, about 120 pounds. (I will admit to being on the round side.)

Part of the reason for this goal is because of a patient who asked me if I had sleep apnea. I told him I did not. I have had a sleep study and my AHI was 2.1. He proceeded to tell me that was impossible because I was so fat.

Well, yeah it is possible. Fat increases the chance of apnea but does not guarantee it. And that led me to the question, am I a sleep tech or a role model?

I am lucky I have a wonderful staff, present and past. I hope I have been a good role model to them. But am I a good role model to my patients as well?

As I am working night shift after working a day shift, going home and scoring, I can definitely say I am not. So here is my list of things I am going to do to make myself a better role model to my staff and to my patients.

• I am going to continue to lose weight with my friends so I can present a healthy exterior to everyone.

• I am going to get at least 30 minutes of sunlight every day. This comes from the article in the December issue of Sleep on helping night shift workers.

• I am also going to do at least five 5k races this year. That is how many there are at Disney if anyone would like to join me.

• I am going to have a more positive attitude. For those who know me I go back and forth between the cup is half empty and the cup is half full. I have some wonderful websites for motivation. If anyone wants them just let me know and I will post them.

• I will also learn something new each day. My favorite site to do that is Ted.com. It has 15 to 20 minute lectures from some of the most interesting people out there on every topic known to man and woman.

Well, that is about it. Anyone who sees me in three months we will see if I can do it. I hope you will share what you are resolving to do. You never know who might have some great advice or a great resources to help you.

As a respiratory therapist and as a sleep tech, I do not think I have ever seen a year with as many changes as this year has brought us.

We started the year on the right note. We knew that competitive bid was coming. Then came the issue of home sleep studies. Following closely on its heals was licensure and respiratory credentials for sleep technicians. And just when you thought we had enough curve balls to handle, the economy tanked and people could no longer afford their co-pays or lost their jobs and their insurance.

I have had many friends and know several labs that were affected by all this change. It is a lot to take in. Many people I know have ignored it or believe that it will not affect them.

As a whole, sleep does not have a strong advocacy group. We have the AAST but many people do not belong. We also have a large group of respiratory therapists who belong to the AARC, which has a much stronger voice.

You do not see state associations in and very few regional ones. I know living in Florida there are two regional associations but then it seems they are competing with each other for members.

We do have some great highlights though. We have several professional magazines, one really phenomenal message board, binarysleep.com, many people who are creating CEU and college programs to teach sleep in a formal setting, and many truly dynamic people who are bringing our profession to a whole new level.

I remember when respiratory was going through the same issues. There were many people who were trained via on the job training; we had credentials but we were not licensed. Those of us who got our AAS degrees were asked why. Why take the RRT? Why worry when we are needed?

I believed in the field of respiratory and was very passionate about it. And I encouraged people to get their credentials because eventually we would be licensed. When that day came, I lost several co-workers because they refused to take the test. I remember all of this and I see history repeating itself.

This is why I know that sleep will do well. Because history shows that these young medical fields are important and that as we grow and change we not only survive but thrive.

I challenge every tech out there to do something great for our field this year. If we work together, publish papers, create state societies, or help new technicians, we will be a strong and healthy profession.

Do you notice how we talk differently to our patients depending on the age and sex of the patient? 

Take the 70-year-old woman who comes in for a sleep study. I find myself always calling her Ms. Smith and will chat with her about the sleep study, and what to expect. It is all very formal. 

You turn off the lights and the only time she will call you is to go to the bathroom in the morning she will inform me that the mask pinched her nose all night but she did not want to be a bother so she did not tell me. 

Now the 70-year-old man I will address as Mr. Smith will either deny that there is anything wrong and no way will he wear that silly thing. 

Now take your 30-year-old woman: if you got her to come in you are pretty talented because she is the busiest person on the face of the earth and never has time for herself.

I usually end up addressing her by her first name because she does not enjoy formality or maybe it is because at least her she is called by her first name and not Sam's mom, or Jake's wife or some other title she has earned like the cookie lady because she has sold girl scout cookies in front of Wal-Mart the last two week.

Now in addition to chatting about the test and the possibility of a second study, I get to hear everything that is going on in her life that is causing her sleep problems. This will include the husband who snores like a freight train, the kids, work, and the container of Chunky Monkey she consumes every Friday night as a reward for getting through the week. By the time we are done with the set up we are best friends. 

But my favorite is any man under the age of 60 who comes in for a sleep study. He is here for 1 reason and 1 reason only: His significant other has sent him because she can not stand listening to him snore for one more day and has sent him to sleep on the couch.

He is willing to admit maybe he snores a little bit but what he wants most is to be able to sleep in his own bed. Of course he does not want to wear that mask under any circumstances but he is willing to take the test and prove his wife wrong. 

While you are setting him up he is not talking to you he is watching Monday night football or Cops. He will insist he never goes to bed before midnight and there is no way he will sleep with all these wires. Then you walk out of the room to set up your next patient and you hear him snoring though the walls.

If he comes back for the second study you will go through the same routine again only when the morning comes you are now his best friend because you just gave him the best night's sleep he has ever had and you did not even have to sleep with him.

Here are some tips to make communication less stressful. It will help put both you and your patients at ease while caring for them.

1. Always use the formal until you are invited to do otherwise. People who prefer less formality will always tell you, but people who prefer formality will go to your supervisor

2. Ask questions. People expect you to ask questions about their condition. They want to know you understand and in many cases that what they are experiencing is not unusual. Let's face it, woman usually think going to the bathroom three times a night is normal, it's nice to hear maybe we can cut the visits down to one.

3. Remember that almost no lab is soundproof, so be careful what you say because you never ever know who is listening. Trust me your patient or co-worker will hold last night's bar experience against you.

Have you ever considered that fact that as sleep technicians and respiratory therapist and anyone else who deals with sleep and CPAPs that we are probably the world's greatest salespeople?

The biggest part of my job is scheduling, ordering CPAPs,and telling patients they need to come back for a second study because they have sleep apnea. In my past I have also done homecare where I would go and set up a CPAP machine for my patient.

Now you call someone after they visit the doctor and invite them to come spend a night with you. You convince the patient that you have a beautiful facility with a flat screen television, a queen size bed and quiet. The last selling point is particularly appealing to our female patients with young children. You explain that you will use tape and paste to attach some wires and that there is a video camera but no one but the doctor and your tech will see the video.

After explaining all this you set the appointment but the patient tells you they are never going to wear one of those masks because their friend told them how awful it was. They then complete the conversation by asking what happens when they are unable to fall asleep.

The night of the test comes.

You show a video that was made about 15 years ago and the only CPAP is large loud, outdated, and has a full face mask attached. The patient usually about this time says there is no way they will ever wear one of those things. You reassure them and bring out nasal pillows and a small nasal mask. We each have our favorites to use. You convince the patient to try holding it to their face and ask them to breathe through their nose.

The usual reaction is one of two. "Wow I can breathe better" or "This is too much I can not handle this."

With the second person you break out your favorite full face mask and tell them to breath through their mouth. That usually helps. You sit with the patient. You chat with them. You have them watch the football game that is on while you set up your other patient. By the time you come back they are relaxed and you have sold another person on how great a CPAP is.

It is probably the hardest sell anyone can ever make but it definitely improves lives every day.

I came to work today thinking it was going to be a normal day.  I got up, dressed, drove my teenager to school because he thinks the bus is evil, and arrived at work.  I currently run a sleep lab and usually work days.  This day just went everywhere in a big hurry.  For one thing it was the day when I was doing my first marketing luncheon at a doctor's office.  Not only that but I was going there with the owner of my lab. 

I arrived, did my work, and headed for the doctor's office with the 2 lasagnas I baked for them (Just so you all know: I am a closet foodie) and met up with the owner and a home care company we were cosponsoring the lunch with.  We go upstairs, set up our equipment and our lunch, and wait. And wait.  And wait. 

An hour later the staff starts arriving. We tell them about our facility, how personalized the services is, and how we work together to get the patient taken care of from start to finish. 

That's when the question comes.  "Have you had any?" 

I looked at the person asking me and say ask "excuse me?" 

She clarifies "Have you gotten any sleep?"

I responded that I had gotten 6 hours last night and she replied she would kill to get 6 hours of sleep. 

Back when I was growing up in the 1970s and early 1980s a comment like that was always about sex.  In fact, other then making fun of our fathers for snoring like a freight train, we never talked about sleep. 

Today we ask that question because what we crave more then anything is rest.  We get up, run to work, run the kids around, do chores, talk to our friends and family, do the work we brought home with us, or the class work from the class we are taking to move up in our career, and then try to spend some quality time with out family. 

What we do not do is rest and sleep.  It has become so bad that if you google ways to improve sleep, you will get over 500,000 web pages on the subject.

Is it possible in this day and age that sleep has become the new sex?  Think about it.